Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
RESEARCH ARTICLE
REASONS FOR MISSING APPOINTMENTS IN GENERAL CLINICS
OF PRIMARY HEALTH CARE CENTER IN RIYADH MILITARY
HOSPITAL, SAUDI ARABIA
Zahi Alhamad
Department of Family and Community Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
Correspondence to: Zahi Alhamad (mezo106@gmail.com)
DOI: 10.5455/ijmsph.2013.2.256-265 Received Date: 07.01.12013
Accepted Date: 07.01.2013
ABSTRACT
Background: Non-attendance in general practice has received increasing attention over the past few years. Its
relationship with access to health care has been recognized. Missed appointments have serious clinical and economic
consequences.
Aims & Objective: This study aims to identify the reasons for missing appointments in general clinics in Alwazarat
health care center during the period from December 2010 to March 2011.
Material and Methods: All eligible patients who missed appointments to general clinics, in Alwazarat center and
controls that show up for their appointment, were enrolled in the study using quasi-randomization for sample
selection. On the same day of missing the appointment three clerks were assigned by the doctor in-charge of the center
to assist in data collection. A structured phone interview was conducted with patients enrolled in the study and the
control group using a validated questionnaire.
Results: The demographic factors associated with missing appointments were: female gender, younger age group and
poor socioeconomic status. The important top five causes for missing appointments were: difficulty booking an
appointment, work commitment, long distance travel, unavailability of transportation, visiting another health care
facility. Among the group who missed appointment, the impact of missing appointment on health care service was
unknown.
Conclusion: Knowledge of the factors that are associated with missed appointments facilitates the prospective
identification of patients at risk of missing appointment and helps the continuous quality improvement for future
planning which may include program modifications, and formulation of strategies to reduce the risk and rate of nonattendance.
KEY-WORDS: Missed Appointments; Primary Health Care; Saudi Arabia
Introduction
Failure to keep scheduled clinic appointments
(missed appointments, no-shows, nonattendance)
is a common problem in ambulatory settings.
Thousands of patients miss their appointments
every year in all kinds of practices including
general practice clinics.[1] Little is known about
which patients miss appointments or why they do
so. At one end of the spectrum such people may be
seen as a vulnerable group with multiple health
problems and difficult lives, while at the other end
they may be considered as nuisances who
repeatedly fail to keep appointments which could
have been used more gainfully for people in
greater need.i Indeed, while missed appointments
may be welcomed by many general practitioners
(GPs), they are clearly seen as a source of
frustration by others.[2]
258
International Rates of missed appointments vary
among countries, and according to practices,
patient mix and type of settings. Studies reported
missed appointment rates in the range of 2% to
30% with higher rates pertaining to psychiatric
settings.[3-7] Locally two studies from Saudi Arabia
eastern and central region found very high rates of
missed
appointments
23.7%
and
30%
[1,8]
respectively. The current prevalence is yet to be
determined.
Missed appointments have serious clinical and
economic impacts. It disrupts continuity of patient
care, delays treatment, and affects doctor–patient
relationship and increases the cost of health care.[4]
The non-attendance of clinic appointments impacts
negatively on patient care, since patients may miss
out on the opportunity to receive treatment or
screening for their illness.[2] Non-attendance of
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2
Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
appointments is one of the major contributors to
poor control in diabetic patients. ii A study
conducted in USA (2005) revealed that missed
appointment was the most significant factor
related to treatment failure.[3]
Missing the appointment and late cancellation
preclude other eligible patients from receiving care
they deserve, exerts a huge strain on the system
and prolongs booking and waiting time in the clinic
for other patients.[9] It also deprives other patients
of earlier appointments which affect their quality
of care.[1] Furthermore, the non-attendance of
prescheduled appointments adds to the
frustrations of health care providers who already
have difficulty in managing the patient load on the
clinics.
Economically, missed appointment has significant
impact on the ability to provide efficient and
effective outpatient services. It results in wasting
financial and social costs.[6,7] A study evaluating the
financial significance of failed appointments
revealed that non-attendance results in allocated
resources not being utilized.[3] The social cost of
missed appointment is the costs of unused or
misused resources such as ward capacity and
possible misuse of patients’ time.[5-8,10,11] This puts
an extra load on the health care system and costs
the ministry of defence a large amount of money
and contributes to depletion of limited resources.
Apart from few studies done in Saudi Arabia[1.8] the
subject of missed appointments was not widely
studied. Fewer studies were carried out in primary
care setting.[3,4] The reasons for missing scheduled
or "booked" appointments in general practice in
Saudi Arabia were not particularly addressed yet.
Previous research has been conducted in a variety
of practice settings in USA[5,12] and Europe[8,9,13] to
elicit determinants of non-attendance. The factors
identified include: younger age, single marital
status, health belief factors, patients who have
larger families and less education, low
socioeconomic class and previous history of missed
appointments; but no factor has been persistently
evident in all studies. The causes in our population
might differ and they are expected to be different
from those in other countries and societies
according to the special cultural, religious and local
characters of the Saudi society.
259
Over the last several years there has been a lot of
apparent development in the health care system
in Saudi Arabia. Hence reasons and prevalence of
non-attendance are expected to have changed
somehow. Factors that were not associated with
the problem at that time could be significant
nowadays, e.g. travel time and travel distance.[8]
In a military population health seeking pattern
and behavior might differ due to the nature of
work and could have an impact on keeping the
appointments of the person and his family as well.
Factors among RMH patients are expected to be
different, especially because no study has been
carried out in Riyadh Military Hospital (RMH) to
identify such reasons. This study is meant to fill an
important gap of knowledge about the Saudi
population (especially military) with regard to
keeping health care appointments. It aimed at
identifying the reasons for missing appointments
in general clinics in one of primary health care
centers in Riyadh during the period from
December 2010 to March 2011.
Materials and Methods
This is a cross sectional study investigating the
rate and causes of missing appointments in
Alwazarat primary health care center in Riyadh at
the end of year 2010 and start of 2011.
In Riyadh military hospital the main family and
community medicine center is located in
Alwazarat neighborhood. Alwazarat family and
community health center is located in the central
area of Riyadh where most of the ministries and
two other hospitals are located in close proximity.
It serves a population of approximately 250,000
most of them being military personnel, ministry of
defense staff and their dependent families. About
forty clinics are being operated daily in sessions
starting from eight o'clock a.m. till four o'clock
p.m. The clinics are run by staff of general
practitioners ranging from senior house officers to
senior family medicine consultants of both
genders.
In addition to general clinics and chronic disease
clinics designed for the follow up of patients of
chronic diseases e.g. diabetes, hypertension,
bronchial asthma, the center includes some
outreach clinics of the main hospital for pediatrics,
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Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
dermatology, ophthalmology antenatal, well baby
and well woman which are being run by
specialized doctors in those fields. Scheduling
appointments in Alwazarat PHC center is being
done by several means; patients can book an
appointment through telephone, RMH website, or
could be referred by the physician or given follow
up appointments in chronic disease clinic. For
general clinics the appointments are booked
within one day only.
All patients who booked appointments to general
clinics, in Alwazarat center, whether the
appointment was made through telephone call,
RMH internet web site or made in person, were
considered eligible. A study group of patients who
missed their booked appointments and a control
group of patients who showed up for their
appointment in the same day were selected until
the total sample size was reached.
Sample Size
The sample size was estimated to determine the
prevalence of any cause of missed appointment of
20% or more, with a 3% absolute precision and a
95% level of confidence. Using the single
proportion equation for dichotomous variables
(Epi-Info 6.04), the calculated sample size was
682 subjects. After adjustment for a dropout rate
of 10%, it was estimated to be 760 subjects, 380
subjects in each group.
A list of non-attendees and controls, which show
up for their appointment, were retrospectively
identified and considered to be enrolled in the
study. A systematic random sample of every third
patient was obtained. Patients were contacted on
the same day of missing the appointment to avoid
recall bias and confounding factors like preweekend days, bad weather and heavy traffic.
Working Definition of Missing Appointment
1. Non-attending patients were defined as
patients who missed at least one prescheduled
appointment with the general clinic in
Alwazarat center during the period from
December 1st 2010 to March 31st 2011.
2. Patients who showed up later than the
appointment time and were not seen were
also classified as non-attending.
260
Inclusion criteria were patients who had scheduled
appointments in general clinics in the study period
were included in the sampling frame. All patients
included in the study were required to be able to
speak and understand Arabic or English. In addition
to guardians on behalf of their children who were 18
years of age or younger. Exclusion criteria were
patients who do not have contact telephone
numbers registered in the system. If a family of two
or more missed an appointment they were counted
as one regardless of their number. In addition to
patients who are unable to respond due to physical
or mental disability.
Three clerks were assigned by the doctor in-charge
of the center to assist in data collection. A structured
phone interview was conducted with patients of the
study and the control group. Each clerk attended a
two-hour training orientation session, and
additional training was gained during the pilot
study.
Clinic appointment records and attendance registers
were used to identify those patients who had
prescheduled appointments and those who failed to
attend. At the end of Session two for each working
day (4 p.m.), a list was made by a senior clerk who
was assigned to this job by the doctor in-charge of
the center. The list included names of the patients,
medical record numbers and the available contact
numbers of all non-attending patients, and controls
for whom contact details were available, from this
list the first and every third patient were selected to
be phoned within one day of missing the
appointment. Consent for the study was obtained
from patients verbally.
If the mobile number was invalid or the call was not
answered the land line was tried if available. If the
person was not available at that time another call
was made within one day before considering the
patient as a non-responder. The phone interview
was conducted by the researcher himself with the
help of two male and one female clerk. The female
clerk conducted the interview with female patients
when appropriate. The assisting clerks received
training on how to conduct the telephone interview
in a standard 2-hour session to minimize
interviewer bias. The calls were made from
Alwazarat center between 3 p.m. and 8 p.m.
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Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
Saturday through Wednesday from December 1st
2010 to 31st March 2011.
The data collection tool in this study is a
questionnaire designed for both defaulters and
controls. It was developed by the researcher to
collect data via telephone interview. Time allocated
for each interview was about an average of seven
minutes (estimated from the pilot study).
The questionnaire was adopted from several
relevant studies. It was modified, appraised and
distributed to three consultants to evaluate it
regarding clarity and suitability to study objective. A
list of 14 items found to be the reasons for missed
appointments in previous studies 14-17 were
identified and administered to respondents. The
initial version of the questionnaire was field tested
as a pilot of about 5% of the total sample size, to test
for applicability. It was revised into its final format
and the time allocated for the phone interview was
adjusted. Issues addressed in the questionnaire
included demographic and socioeconomic data,
satisfaction with overall past clinic experience, and
reasons for missing appointments.
The study protocol was submitted for approval to
the Research Committee of the Family and
Community Medicine department in Riyadh Military
Hospital. Verbal consent was obtained from all the
participants in the study by phone and all
participants were reassured regarding the
anonymity and confidentiality of the study results
and that this study was not going to affect their
future access to health care services.
Data Entry and Analysis
Data was entered on daily basis directly into SPSS
program, version 17 which was used for analysis.
Demographic and socioeconomic factors of both
groups were analyzed and compared. The two
groups were compared, using Chi squared as the
main statistical significance test to assess the
difference between the study and control groups.
Results
The study included 750 subjects of which 653
subjects agreed to participate in the study and
completed the telephone based questionnaire giving
a response rate of 85.9 %. Around 14 % of patients
261
in both groups declined to participate in the study or
could not be reached after several attempts. The
response rate in the study group was (84%) and in
the control group was (86%).
Table 1 shows the basic demographic characteristics
of the participants in study and control groups. Male
participants in the missed group were significantly
lower than females, 23.1 % vs. 76.9 % respectively.
More than 60% of participants in both groups were
below the age of 40. Around 52.3% of the
participants had a crowding index of less than one.
Around 78.4 % of patients in the missed group had a
crowding index of One or more as compared to
69.3% in the control group (P = 0.008). There was
no relationship between the marital status and
adherence to appointment. Results showed that
number of children in the family was not a
significant factor for missing appointment (P= 0.8).
The level of education was found to be of a
significant factor between the two groups only at the
level of patients who were illiterate or without
formal education, where these were more in the
group who missed an appointment. The distribution
of other classes of education was similar in the two
groups. Employed participants were significantly
higher in control group compared to the group who
missed the appointment. Regarding the means of
transportation it was patients who used their own
cars who were more likely to keep their
appointments. More people in the missed group
were dependent on others to drive them to the clinic
than in control group, 78.7% vs. 51.9% respectively.
Table 2 shows the causes that were associated with
missing appointment. Most frequently reported
causes by study group were: difficulty booking an
appointment,
long
distance
travel,
work
commitment, unavailability of transportation and
visiting another health care facility. The overall
reasons for missing appointments ranked in
descending order. Most frequent causes for missing
appointment reported by both groups in descending
order were: difficulty booking an appointment, work
commitment, long distance travel, unavailability of
transportation and visiting another health care
facility are the top factors mentioned.
Table 3 demonstrates the factors associated with
missing appointments. the trip duration between
the two groups was not a significant factor. Patients
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2
Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
who missed an appointment were more likely to be
dependent on others for transportation (P=0.001).
People in the missed appointment group were
significantly more likely to have missed an
appointment in the past than their controls 63.4%
Vs 43.5% (P=0.001). The mean frequency of missing
appointment in the Missed appointment group is
significantly higher than that in the Control group. It
indicated that defaulters showed a significantly
greater tendency to miss more appointments
compared to controls. (P=0.02). Patients who kept
their appointments expressed more dissatisfaction
with the service than patients who missed the
appointment and vice versa.
Table-1: Demographic Data of the Missed Appointment
Group and Controls
Group
P
Missed
Control
Variable
χ2
value
(N=347)
(N=306)
N (%)
N (%)
Gender
Male
80 (23.1) 146 (47.7)
43.7 0.001
Female
267 (76.9) 160 (52.3)
Age
0-20
73 (21)
36 (11.7) 10.05 0.001
21-40
162 (46.7) 168 (55) 4.39 0.03
41-60
83 (23.9) 79 (25.8) 0.31 0.57
60+
29 (8.4)
23 (7.5) 0.16 0.69
Crowding index
<1
75 (21.6) 94 (30.7)
7.03 0.008
1+
272 (78.4) 212 (69.3)
Marital status
Single
36 (10.4)
29 (9.5)
Married
294 (84.7) 267 (87.3) 1.3 0.52
Divorced/ widow
17 (4.9)
10 (3.3)
No. of children
Zero
87 (25.1) 81 (26.5)
1-2
95 (27.4) 79 (25.8)
3—4
96 (27.7) 87 (28.4) 1.3 0.856
5—6
49 (14.1) 37 (12.1)
7 or more
20 (5.8)
22 (7.2)
Educational level
No Formal Education
73 (21)
32 (10.4) 6.38 0.01
(Illiterate/read & write)
Basic Education
(Elementary/
60 (17.3) 87 (28.4) 3.28 0.07
Intermediate)
high school/ Diploma 161 (46.4) 139 (45.4) 0.04 0.84
university level
53 (15.3) 48 (15.7) 0.02 0.88
Employment status
Employed
105 (30.3) 139 (45.4)
15.9 0.001
Unemployed
242 (69.7) 167 (54.6)
Town of residence
Riyadh
338 (97.4) 294 (96.1)
0.92 0.337
Out of Riyadh
9 (2.6)
12 (3.9)
Table 4 shows the awareness of the impact of
missing appointments. Patients in the control group
were more aware of the impact of missing
262
appointments on the service than those in the study
group 74.2% Vs. 64.3% respectively, the difference
been statistically significant. Both groups are
similarly aware of the impact of missing
appointments on their health.
Table-2: Causes of Missing Appointments Reported by
Patients who missed an appointment and their controls,
arranged in descending order of frequency according to
the Missed group
Group
P
Missed Control
Reasons
χ2
value
N=347* N=306*
N (%)
N (%)
Difficulty in booking
159 (45.8) 138 (45.1) 0.03 0.85
appointment
Long distance travel
119 (34.3) 108 (35.3) 0.07 0.78
Work commitment *
113 (32.6) 132 (43.1) 7.75 0.005
Unavailability of
112 (32.3) 104 (34) 0.30 0.58
transportation
Visiting another health care
facility or alternative
65 (18.7) 55 (18) 0.06 0.80
medicine.
child care
49 (14.1) 30 (9.8) 2.85 0.09
Not having a companion.
40 (11.5) 34 (11.1) 0.03 0.86
Inconvenient appointment
38 (11) 47 (15.3) 2.8 0.09
time
Feeling better
23 (6.6) 30 (9.8) 2.2 0.13
Forgetting the appointment
20 (5.8) 38 (12.4) 8.9 0.002
*
Mix up over the date/time
of the appointment by pt or 13 (3.7)
9 (3) 0.32 0.56
practical error
Not being well enough to
10 (2.8) 13 (4.2) 0.89 0.34
attend
Long waiting time at the
clinic from previous
experience/ Perception of
6 (1.7) 42 (13.7) 34.3 0.001
Disrespect by the Health
Care System *
financial difficulties
5 (1.4)
8 (2.6) 1.15 0.28
Others
16 (4.6) 20 (6.5) 1.16 0.28
* Responses are not mutually exclusive.
Table-3: Factors Associated with Missing Appointments
Group
P
Factors
χ2
Missed
Control
value
N (%)
N (%)
< 30
67 (19.3) 70 (22.9)
Trip Duration
31 – 60 233 (67.1) 196 (64.1) 1.25 0.53
(minutes)
> 60
47 (13.5) 40 (13.1)
Means of Dependent 273 (78.7) 159 (51.9)
51.8 0.001
Transport Independent 74 (20.3) 147 (48.0)
Previously
Yes
220 (63.4) 133 (43.5)
Missed
26.02 0.001
No
127 (36.6) 173 (56.5)
Appointment
Dissatisfied 15 (4.5) 37 (12.8) 13.4 <0.001
Patient’s
Neutral
21 (6.3) 29 (10.0) 2.7 0.10
Satisfaction
Satisfied 300 (89.3) 224 (77.3) 18.0 <0.001
Mean frequency of missing
1.56
1.36
0.026#
appointments
* Driven by a relative/taxi; ** own car/own driver; # P-value of
Mann-Whitney test
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Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
Table-4: Awareness
Appointments
Reasons
On Health Care
Services
On Health
Yes
No
Yes
No
of
the
Impact
Group
Missed Control
N (%)
N (%)
223 (64.3) 227 (74.2)
124 (35.7) 79 (25.8)
321 (92.5) 289 (94.4)
26 (7.5) 17 (5.6)
of
Missing
χ2
P
value
7.47
0.006
0.99
0.32
Figure-1:
Percentage
of
Patients
Favouring
Confirmation of Appointments in the Missed
Appointment Group and Control
Figure-2: Percentage of Patients Favouring Certain
Appointment Confirmation Method
Figures 1 and 2 show that the vast majority of
patients, in both groups, prefer to be reminded of
their appointments, and most of them, prefer the
confirmation with an SMS on their cell phones.
Discussion
The response rate reported in the present study is
magnificent. It was possible with the continuous
support of the department administration and fully
dedicated data collectors who worked around the
day including afternoon sessions and after hours to
maximize the chances of patient availability and
response. Most of the other studies done on this
topic had variable and unpredictable response
rates which ranged from 25% to 93% for studies
conducted through telephone interviews.[11, 25]
263
The reasons for missing appointments in this study
were approached on three main dimensions that is;
the socio-demographic characteristics, what the
patient perceives as cause of the problem and what
could be verified as one through comparison with
the control group. Regarding demographic
variables female gender, young age group and poor
socioeconomic status; in terms of high crowding
index, lack of formal education and unemployment,
were the factors associated with missing
appointments. Neal RD et al. studied missing
appointments in U.K. at primary care level and
found female gender to be associated with missing
appointments.[3] This study shows the same finding
again despite that other local studies did not detect
such a difference.[19] This disagreement could be
due to different study methodology and population.
This study shows that young patients below twenty
years are more likely to miss an appointment than
older patients. Patients between 21 and 39 years of
age are more likely to keep theirs. The possible
explanation for this observation could be the larger
young population proportion in the community
which is represented in the study sample.
According to World Health Organization statistics
in 2009, youth constitute the majority population
in the Kingdom of Saudi Arabia.[3] R D Neal et al,
and Nour El-Din et al. found that younger patients
were more likely to miss appointments and
missing appointments decreases with increase of
age.[1,2]
By doing sub-group analysis of those patients
below twenty years of age the most commonly
cited cause for non-attendance in both groups was
difficulty booking an appointment followed by
visiting another health care facility. It is known that
acute illnesses are more common in younger age
group. Parental anxiety at the time of acute illness
and fearing the consequences of delayed medical
consultation might lead to seeking urgent care e.g.
Emergency department care, and hence not
showing for the clinic appointment. Other top
causes were related to parents' or guardians'
limitations i.e. work commitment, long distance
travel, child care and unavailability of
transportation. Grruzd et, al. and Vikander et, al.
reported better adherence to appointments in
patients with chronic illness.[3,4]
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Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
Income, education, occupation and wealth are the
important determinants of socioeconomic status.
Crowding index is a tool used to assess
socioeconomic status and income. It was found that
socioeconomic status is a key factor for utilization
of health care. Low socioeconomic level and living
in deprived areas are indeed related to the
deterioration of health care and its related
measures including missing appointments.[2] In
consistence with that, this study shows that,
compared to controls, defaulters were more likely
to: have a higher crowding index, lack formal
education and be unemployed. As a result it is
reasonable to conclude that missing appointments
is associated with low socioeconomic status. Waller
J et al, found that patients who miss appointments
tend to come from a lower socio-economic class.[4]
Neal RD, and others found that living in deprived
area is associated with missing appointments in
general clinics.[2,10] Several studies done in USA
found
that
socioeconomic
class
is
of
[13,14,31]
importance.
Some of deprived groups also consult more, and it
may be that they miss more appointments as a
result of their making more appointments. Neal RD
et al found that over 90% of the patients who
missed an appointment subsequently consulted
within three months and of these nearly 60%
consulted for the stated problem that was going to
be presented in the missed consultation.[28] It can
be referred to as “Default as a function of
attendance”.[3] Having a lower socioeconomic class
is associated with having less education, being
unemployed and having fewer resources.
Non-attenders are less likely to own a car or a
telephone and are more likely to be unemployed.[35,34] The effect of educational level was not detected
in other studies, which may be due to smaller
sample size.[3] The effect of socioeconomic factors
cannot be ignored when looking at the reasons for
missing appointments.
Most of the reasons mentioned for missing
appointment did not differ significantly between
study group and controls. The following reasons
were most frequently mentioned to justify missing
an appointment by both groups : difficulty booking
an appointment, work commitment, long distance
travel, unavailability of transportation, visiting
another health care facility, inconvenient
264
appointment time, child care, not having a
companion, forgetting the appointment, feeling
better, long waiting time / perception of disrespect
by the health care system. This order is very
similar to reasons found in other studies in U.S.A,
U.K. and K.S.A.[1,9,18,19,21] Among the above
mentioned reasons, work commitments, long
waiting time and forgetfulness were cited more by
controls (P<0.05).
The first category of reasons is related to
transportation. Missing appointments due to long
distance, the most frequently cited reason, could be
affected by other factors such as unavailability of
transportation and financial difficulties. Easily
accessible location of a health care center is very
important part of access to care. Despite that the
majority of participants (~97%) were residents in
Riyadh, and the study center being located in the
central area, long distance travel was a leading
cause of missing appointments in the study group.
Factors to blame could be centralization of health
care to one center and traffic jams. Riyadh is a big,
quickly growing and very crowded city. It has more
than four major sections. Traffic jam problems
have received a lot of formal and public attention in
the last few years. Our results show that one-way
trip to Alwazarat center takes about 31- 60
minutes for more than 60% of patients in either
group.
Finding transportation was a major problem for
unemployed, females, with no-formal education.
Transportation system in Saudi Arabia is based
solely on private vehicle transportation. Driving
and driver’s license is limited to males who are
eighteen years of age or older. Other options for
transportation are personal drivers and taxis,
which are relatively expensive. Sometimes it is
socially not acceptable for females to use the latter
two without the company of a chaperon. Public
transportation is not developed yet and not used
by people for everyday within-city transportation.
This could explain why the majority of patients
with transportation difficulties are unemployed
female patients. Around 78% of patients who
reported unavailability of transportation were
unemployed, majority of whom were females. Not
working appears to create a hardship for getting
transportation to an appointment. Detman et al.
found that lack of formal education and
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2
Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
unemployment is linked to transportation
problems leading to missing appointments.
Patients who did not have formal education and
those who were not working, were three and four
times, respectively, more likely to report being
unable to get a ride to the clinic as a barrier to
keeping an appointment.[10] G Van der Meer and
J.W. Loock found that Transportation constraints
and long distance are the main reasons for missing
appointments among cancer patients in South
Africa.[38] It is not immediately clear why not
working should prevent finding transportation to
the clinic. Besides having better financial resources
and being able to afford it, one possible explanation
is that working men and women usually arrange
for their work transportation which makes it easier
to arrange for a ride for other purposes. The lack of
a ride to the clinic is also a structural problem.
Individuals lacking adequate means to get to the
clinic experience hardship that is further
exacerbated structurally by less than accessible
public transportation and limited governmentfunded transportation.
Financial constraints could restrict some people
from getting a ride to the clinic. Alshammary et al.,
thought that the economic factors were irrelevant
in terms of cost of health care as the service in
governmental hospitals in Saudi Arabia is free.[19,20]
That being true, the most pronounce effect of poor
financial resources could be projected again on
transportation, especially because income and
crowding index figures point towards limited
affordability of paid transportation.
The second category of reasons is related to
commitments and logistic difficulties. Sometimes
patients miss doctor appointments because they
have to manage other responsibilities, e.g. child
care, work commitments, or because they do not
have the necessary support e.g. not having a
companion, or a baby sitter. According to other
responsibilities the appointment time could be
viewed as inappropriate. Those who reported child
care as a reason for missing appointment were
more in the study group. However, number of
children was not significant factor. Campbell et al.
identified child care as a cause for missing
appointments. [3] Waller J. et al, and Beauchant S. et
al. suggested that patients with low paid jobs may
have difficulty in getting time off work or arranging
265
childcare.[4,35] Some patients, especially elderly and
the less educated, face greater difficulty finding
their way around new places. Not having a
companion would lead to missing appointments for
such groups. The time restriction resulting from
appointment system is almost inevitable. Patients
might not always have a choice to decide the
appropriate time for their appointment. Enabling
patients to do so might help reducing rate of nonattendance. While short booking has its advantages
it comes to a down side when patient has other
commitments and need to re-arrange their
schedule in one day notice. Work commitment
could be looked at from two angles. It could be of
the patient himself or a person on whom the
patient is dependent for transportation or escort,
especially females, children and elderly who are
more dependent on others for these matters. This
could explain the higher prevalence of missing
appointments in the younger age group.
Forgetfulness as a cause of default was reported in
the literature[9,10,19] Neal R. reported a prevalence
of 40% in a study that included patients from seven
practices in Yorkshire.[28] Contrarily in this study it
was reported more in the control group in
comparison to defaulters. As a matter of fact
significantly fewer defaulters reported forgetting
the appointment as a reason compared to controls
(5.8% Vs 12.4%) (P=0.002). This might indicate
that forgetting the appointment is rather used as
an excuse than a real cause. Sometimes patients
will realize late that they will not be able to attend,
or that they don’t need to because they feel better.
The lack of a clear and easy policy for cancelling
appointments is a major concern. Large brochures
and printed instruction leaflets on how to make
and cancel appointments would be appropriate.
Local studies found a relationship between the
duration of intervals between appointments and
keeping them and related that to forgetfulness of
the appointment.[1,19,20] These studies were
conducted in outpatient settings in secondary and
tertiary hospitals, where appointments could be
scheduled after weeks or months. This issue is
eliminated in our setting of general primary care
clinics where booking is initiated by patients one
day prior to appointment time. In a study done in
U.S. forgetting an appointment was cited as a top
reason for missing both prenatal and paediatric
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2
Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
appointments despite current health department
policy to phone clients with scheduled
appointments the day before to remind them of the
appointment. Costa et al, found that adoption of a
reminder /recall system is successful in reducing
rate of missing appointments.[3] Wilkinson M.
suggested that the default rate of frequent nonattenders can be reduced by sending a simple
letter, the effect lasting at least nine months. The
subsequent number of booked appointments may
also be reduced.[3]
Dissatisfaction was expressed more in control
group compared to defaulters. Dissatisfaction was
shown also in the reasons mentioned for missing
an appointment in this group such as long waiting
time and perception of disrespect (P<0.05). This
finding could not be directly explained. The data
collection method could have led to interviewer
bias which might play a role in this result. Realizing
that long waiting time might affect rate of keeping
appointments most of patients did not realize that
prolonged waiting time is further enhanced by
missing appointments and disrupting the clinic
schedule. Other studies reported significant effect
of patient satisfaction with services as a factor for
adherence to appointments, patients who were
satisfied with the service kept their appointments
better.[3,7,21]
Lack of awareness of impact of missing
appointments on the service is thought to play an
important role. Most patients in the missed
appointment group were unaware of the
implications of missing appointments. Lacy et al.
found that patients were unaware of the financial
impact of failed appointments and believed missing
appointments may actually be a positive event for
the clinician and staff.[7] there was no significant
difference in patients beliefs regarding the impact
of missing appointments on their health, between
the two groups. Apathy i.e. being careless is
thought to stand out when looking at patterns of
habitual defaulting. It can be a factor that is
somehow related to human nature, dissatisfaction
and lack of rules. Humans tend to ignore
regulations if there were no potential
consequences. The habitual pattern is significantly
more obvious among the missed appointment
group. Murdock et al suggest that patient apathy
plays a large role in the current burden of missed
266
appointments.[23] Cosgrove reported
defaulting as a significant factor.[34]
habitual
This study shows better adherence to
appointments in patients who are coming for
follow up of a chronic problem, general check-up or
obtaining a referral to a specialist. Nour El-Din et
al. found that visiting the clinic to obtain results of
investigation was associated with higher rates of
adherence to appointments.[1] Gruzd et al. and
Vikander et al. reported better adherence in
patients with chronic illness.[30,31] An explanation is
that people who has chronic illnesses and have
regular follow up tend to be more aware of the
importance of appointments. The effect of that
could be confounded by age and other factors.
People who come for general check-up usually
have higher level of self-care. It was reported in the
literature that reason of visit is not a significant
factor. A study conducted in Switzerland did not
find any significant effect of the reason of visits on
the rate of missed appointments.[22]
Other sporadic causes included among others:
having to leave on a mission for work,
oversleeping, having car trouble or an accident,
unexpected visitors and having another
appointment in the main hospital.
Conclusion
Conclusively, females and younger age patients
tend to miss their appointments more than others.
The important top five causes of missing
appointments were: difficulty booking an
appointment, work commitment, long distance
travel, and unavailability of transportation and
visiting another health care facility. Developing a
flexible, easily accessible, interactive appointment
system with Reminder / Recall system is highly
recommended.
References
1.
2.
3.
Nour Eldin M, Al-Shakhs FN, Al-Oudah S. Missed
Appointments at a University Hospital in Eastern Saudi
Arabia: Magnitude and Association Factors. J Egypt
Public Health Assoc 2008; 83(5- 6): 415-433
Neal RD, Lawlor DA, Allgar VL, Colledge M, Ali S, Hassey
A, et al. Wilson. Missed appointments in general
practice: retrospective data analysis from four practices.
Br J Gen Pract 2001; 51: 830-832.
Beecham L. Missed GP appointments cost NHS money.
[News extra.] BMJ 1999; 319: 536.
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2
Zahi Alhamad. Reasons for Missing Appointments in Primary Health Care Centers
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Waller J, Hodgkin P. Defaulters in general practice: who
are they and what can be done about them? Fam Pract
2000; 17: 252-253.
Johnson BJ, Mold JW, Pontious JM. Reduction and
management of no shows by family medicine residency
practice exemplars. Ann Fam Med. 2007; 5(6): 534-9.
Penneys NS, Glaser DA. The incidence of cancellation
and nonattendance at a dermatology clinic. Am Acad
Dermatol. 1999; 40 (5): 714-8.
Lacy NL, Paulman A, Reuter MD, Lovejoy B. Why we
don't come: patient perceptions on no-Shows. Ann Fam
Med. 2004; 2 (6): 541-5.
Griffiths J. Missed appointments rise by 60%. GP 2001;
August 24: 7.
Mohamed BA, Al-Doghaither AH. Missed appointments
at public hospitals in Riyadh, Saudi Arabia. Saudi Med J.
2002; 23(4):388-92
Detman, LA, Gorzka, P. A Study of Un-kept Appointments
in a Florida County Health Department. Paper
presentation at the One Goal Summer Conference,
Tampa, Florida, July 2000. Available from URL (accessed
on
15/7/2011):
http://health.usf.edu/publichealth/chilescenter/pdf/mi
ssed%20appointments.pdf
Mollentze WF, Koning JMM. Where have all the diabetics
gone? S Afr Med J. 2007; 97: 6.
Berg MB, Safren SA, Mimiaga MJ, Grasso C, Boswell S,
Mayer KH. Non-adherence to medical appointments is
associated with increased plasma HIV RNA and
decreased CD4 cell counts in a community-based HIV
primary care clinic. AIDS Care. 2005; 17(7): 902-7.
Denberg TD, Coombes JM, Byers TE, Marcus AC,
Feinberg LE, Steiner JF, et al. Effect of a mailed brochure
on appointment-keeping for screening colonoscopy. Ann
Intern Med. 2006;145(12):895-900.
Zailinawati AH, Ng CJ, Nik-Sherina H. Why do patients
with chronic illness fail to keep their appointment? A
telephone interview. Asia Pac J Public Health.
2006;18(1):1-2.
Moore CG, Wilson-Witherspoon P, Probst JC. Time and
money: effects of no-shows at a family practice
residency clinic. Fam Med 2001;33: 522–7.
Ngwenya BT, Van Zyl DG, Webb EM. Factors influencing
non-attendance of clinic appointments in diabetic
patients at a Gauteng hospital in 2007/2008. JEMDSA
2009;14(2):106-109.
Martin C, Perfect T, Mantle G. Nonattendance in primary
care: the views of patients and practices on its causes,
impact and solutions. Fam Pract. 2005; 22(6): 638-43.
Bech M. The economics of non-attendance and the
expected effect of charging a fine on non-attendees.
Health Policy. 2005; 74(2): 181-91.
Al-Shammari SA. Failures to keep primary care
appointments in Saudi Arabia. Fam Pract Res J 1992; 12:
171–176.
Al-Shammari SA, Ali M, Alshammari AR, Armstrong K.
Prevalence of No-shows at a family practice clinic, King
Fahad National Guard Hospital, Riyadh. Saudi Med J
1993; 14 (6):527-531
George A, Rubin B. Non-attendance in general practice: a
systematic review and its implications for access to
primary health care. Fam Pract. 2003; 20(2):178-84.
Lehmann TN, Aebi A, lehmann D, Balandraux Olivet M,
Stalder H. Missed appointment at Swiss university
outpatient clinic. Public Health. 2007; 121(10):790-9.
Murdock A et al. Why do patients not keep their
appointments? J R Soc Med, 2002;95:284-6.
267
24. Barron WM. Failed appointments: Who misses them,
why they are missed, and what can be done. Prim Care.
1980; 7(4): 563-574.
25. Kiefe CI, Harrison PL. Post-hospitalization follow-up
appointment-keeping among the medically indigent.
Journal of Community Health 1993; 18(5): 271-282.
26. Mirotznik J, Ginzler E, Zagon G, Baptiste A. Using the
health belief model to explain clinic appointmentkeeping for the management of a chronic disease
condition. J Community Health1998, 23(3): 195-210.
27. Pesata V, Pallija G, Webb AA. A descriptive study of
missed appointments: families’ perceptions of barriers
to care. J Pediatr Health Care. 1999, 13: 178-182.
28. Neal RD, Gambles MH, Allgar VL, et al. Reasons for and
consequences of missed appointments in general
practice in the UK: questionnaire survey and
prospective review of medical records. BMC Family
Practice 2005, 6:47.
29. World Health Organization Statistics. Available from
URL
(last
accessed
on
14/7/2011):
http://www.emro.who.int/emrinfo/index.aspx?Ctry=sa
a
30. Gruzd DC, Shear CL, Rodney WM. Determinants of noshow appointment behavior: the utility of multivariate
analysis. Fam Med 1986; 18: 217–220.
31. Vikander T, Parnicky K, Demers R, Frisof K, Demers P,
Chase N. New patient no shows in an urban family
practice center: analysis and intervention. J Fam
Practice 1986; 22: 263-268.
32. Oppenheim GL, Bergmann JJ, English EC. Failed
appointments a review. J Fam Pract 1979;8:789-796.
33. Goldman L, Freidin R, Cook EF, Eigner J, Grich P. A
multivariate approach to the prediction of no-show
behavior in a primary care centre. Arch Intern Med
1982;142: 563-567.
34. Cosgrove MP. Defaulters in general practice: reasons for
default and patterns of attendance. Br J Gen Pract
1990;40,50-52.
35. Beauchant S, Jones R. Socio-economic and demographic
factors in patient non-attendance. Br J Healthcare
Manage 1997;3:523-8.
36. Sharp DJ. Non-attendance at general practices and
outpatient clinics. BMJ 2001; 323:1081–2
37. Killaspy H, Banerjee S, King M, Lloyd M. Prospective
controlled
study
of
psychiatric
out-patient
non-attendance. Characteristics and outcome. Br J
Psychiatry 2000;176:160-5.
38. Van der Meer G, Loock JW. Loock. Why patients miss
follow up appointments: a prospective control-matched
study. East Afr J Public Health. 2008 Dec;5(3):154-6.
39. Campbell JD, Chez RA, Queen T, Barcelo A, Patron E. The
no-show rate in a high-risk obstetric clinic. J Womens
Health Gend Based Med. 2000 Oct;9(8):891-5.
40. da Costa TM, Salomão PL, Martha AS, Pisa IT, Sigulem D.
The impact of short message service text messages sent
as appointment reminders to patients’ cell phones at
outpatient clinics in São Paulo, Brazil. Int J Med Inform.
2010 Jan;79(1):65-70.
41. Wilkinson M J B. Effecting change in frequent nonattenders. Br J Gen Pract, May 1994;233.
Cite this article as: Alhamad Z. Reasons for Missing
Appointments in General Clinics of Primary Health Care
Center in Riyadh Military Hospital, Saudi Arabia. Int J Med
Sci Public Health 2013; 2:258-267.
Source of Support: Nil
Conflict of interest: None declared
International Journal of Medical Science and Public Health | 2013 | Vol 2 | Issue 2